Americans have prolonged life but with multiple medical conditions making their health care ever more demanding. Being able to define and measure patient complexity has important implications for how care is organized, how physicians and health care systems are paid, and how resources are allocated. In an article in the Dec. 20 Annals of Internal Medicine, a team of Massachusetts General Hospital (MGH) researchers report finding that primary care physicians define patient complexity using a broader range of factors - including mental health, social factors and financial issues - than do commonly used approaches based only on diagnoses and prior costs.
"Simply counting the number of co-morbid conditions does not really capture whether a patient is complex," explains Richard W. Grant, MD, MPH, the paper's lead author. "All primary care physicians can point to patients of theirs with very complicated medical histories who are relatively straightforward to manage, whereas other patients can be a real challenge despite relatively few medical diagnoses. Our results emphasize the importance of social and behavioral contexts that can create important barriers to delivering high-quality primary care."
The study enrolled 40 primary care physicians from 12 MGH-affiliated practices and community health centers. Participating physicians used a web-based tool to review a list of 120 of their own patients and indicated those who, in their view, were complex. For those complex patients, they were asked to indicate which of five domains - medical decision-making, coordinating care, mental health or substance abuse problems, health-related behaviors, and social or economic circumstances - were involved in that determination.
"Managing complex patients requires greater clinician effort, increased health care resources, and substantial family and community support," says Grant, who recently joined the division of Research at Kaiser Permanente Northern California. "In order to redesign our health care systems to more effectively care for complex patients, we need a better handle on exactly who they are. By asking primary care physicians about their experiences with their own patients in a systematic and quantitative way, we were able to bring out the importance of social and behavioral factors, in addition to specific medical problems. This work may help guide efforts to redesign health care systems so that we can deliver high quality, cost-effective care tailored to individual patient needs."